The impact of asthma and its treatment on growth: an evidence-based review

Current Challenges in Pediatric Asthma

Asthma is a chronic lung disease characterized by reversible bronchoconstriction and inflammation of the bronchi. Its increasing prevalence in childhood as well as different triggers make asthma a challenging disease in several ways: defining its phenotype/endotype, the diagnostic approach (especially in younger children), therapeutic options, and systematic follow-up. Considering these problems, this review approaches the current status and limitations of guidelines used for asthma management in children. It also emphasizes the key points which could lead to a better understanding and the direction to take in future studies.

Recommendations for asthma monitoring in children: A PeARL document endorsed by APAPARI, EAACI, INTERASMA, REG, and WAO

Monitoring is a major component of asthma management in children. Regular monitoring allows for diagnosis confirmation, treatment optimization, and natural history review. Numerous factors that may affect disease activity and patient well-being need to be monitored: response and adherence to treatment, disease control, disease progression, comorbidities, quality of life, medication side-effects, allergen and irritant exposures, diet and more. However, the prioritization of such factors and the selection of relevant assessment tools is an unmet need. Furthermore, rapidly developing technologies promise new opportunities for closer, or even "real-time," monitoring between visits. Following an approach that included needs assessment, evidence appraisal, and Delphi consensus, the PeARL Think Tank, in collaboration with major international professional and patient organizations, has developed a set of 24 recommendations on pediatric asthma monitoring, to support healthcare professionals in decision-making and care pathway design.

A multicenter randomized, double-blind, placebo-controlled, parallel-group study to evaluate the effects of a 1-year regimen of orally inhaled fluticasone furoate 50 µg once daily on growth velocity in prepubertal, pediatric participants with well-controlled asthma

INTRODUCTION

Growth impairment is a known adverse event (AE) of corticosteroids in children. This study aimed to assess the effect of once-daily (QD) inhaled fluticasone furoate (FF) versus placebo on growth velocity over 1 year in prepubertal children with well-controlled asthma.

MATERIALS AND METHODS

This randomized, double-blind, parallel-group, placebo-controlled, multicenter study (NCT02889809) included prepubertal children, aged 5 to <9 years (boys), and 5 to <8 years (girls), with ≥6 months' asthma history. Children received inhaled placebo QD plus background open-label montelukast QD for a 16-week run-in period and were then randomized 1:1 to receive inhaled FF 50 μg QD or placebo QD (whilst continuing background open-label montelukast) for a 52-week treatment period. The primary endpoint was the difference in growth velocity (cm/year) over the treatment period. Other growth endpoints were measured, as were incidence of AEs and asthma exacerbation. Growth analyses included all intent-to-treat (ITT) participants with ≥3 post-randomization, on-treatment clinic visit height assessments (GROWTH population).

RESULTS

Of 644 children in the run-in period, 477 (mean age 6.2 years, 63% male) entered the 52-week treatment period (ITT population: FF N = 238, placebo N = 239; GROWTH population: N = 457 [FF N = 231; placebo N = 226]). The least-squares mean difference in growth velocity for FF versus placebo was -0.160 cm/year (95% confidence interval: -0.462, 0.142). There were no new safety signals.

CONCLUSIONS

Over 1 year, FF 50 μg QD had a minimal effect on growth velocity versus placebo, with no new safety signals.

Retrospective cohort analysis of weight changes during the COVID-19 pandemic in a pediatric asthma population

OBJECTIVE

To investigate the BMI trajectories of children attending a tertiary asthma clinic during the COVID-19 pandemic.

METHODS

Data were collected retrospectively on children and young people with asthma who attended the Royal Hospital for Children and Young People (RHCYP) before March 2020 (pre-COVID-19) and after August 2021 (the lifting of national restrictions).

MAIN OUTCOME MEASURES

Changes in weight, height, and BMI Z score measured between 13/03/2019 and 13/03/2020 (timepoint 1) and then again during the period 01/08/2021 to 01/10/2022 (timepoint 2); changes in lung function parameters (FEV1) between the timepoints; proportion of study sample classed as obese and overweight at both timepoints; interaction analyses according to deprivation indices (SIMD decile), the use of high dose inhaled corticosteroid (ICS) therapy, and the presence of atopy.

RESULTS

Eighty-nine children aged 5-18 years were studied. Weight and height Z scores significantly increased between timepoint 1 and 2 [weight Z score: +0.19 (0.08, +0.30), height Z score: +0.15 (+0.07, +0.23)], such that no significant change was observed in the BMI Z score [+ 0.07 (-0.05, +0.20)] or BMI centile [+0.5 (-3.1, +4.1)]. There was also no change in FEV1%predicted [-0.1 (-3.8, +3.6)] between the timepoints.

CONCLUSIONS

No changes in BMI were observed in children with asthma before and after COVID-19 lockdowns. Improved linear growth was noted, implying an improvement in the overall physical health of our study cohort. This may suggest improved asthma control, which may reflect avoidance of viral triggers and/or improved adherence to treatment.

Uncontrolled Asthma Among Children and Its Association With Parents’ Asthma Knowledge and Other Socioeconomic and Environmental Factors

Objective To estimate the frequency of uncontrolled asthma among asthmatic children from Jeddah and to analyze its association with parental asthma knowledge and other socioeconomic and environmental factors. Method A cross-sectional study was conducted at the Pediatrics Departments of King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from July to December 2018. It involved the caregivers of 150 children with asthma, who were following at KAUH. A structured questionnaire was administered by a phone interview to collect the following: socioeconomic and environmental factors of asthma, answers to the Arabic version of the Asthma Control Test^TM (ACT), and answers to the Arabic version of the caregiver Asthma Knowledge questionnaire (AKq). Result The frequency of uncontrolled asthma was 32.7% (95%CI: 25.2 - 40.8). Parents had myths about asthma such as "children with asthma should use asthma control medications (inhaled corticosteroids) only when they have symptoms" and "it's not good for children to use the inhaler for too long". Besides, we observed mixed results regarding parents' knowledge about the disease, with correct answers ranging from 56.0% to 88.7% depending on the item. Exposure to bakhoor (aromatic woodchips) at home (OR = 0.41, p=0.044), two or more ICU admissions during the past 12 months (OR = 3.30, p=0.030), and using a rescue inhaler even if there's no cough or wheeze when the child gets the flu (OR = 0.22, p=0.001) were the three independent factors of uncontrolled asthma among children. Conclusion Uncontrolled asthma concerns one-third of the asthmatic children following at our centre, representing a less concerning figure compared to the national data. The contribution of parents' knowledge to asthma control did not show significant results, although uncontrolled asthma may represent an opportunity to increase parents' knowledge and awareness. We emphasize the significance of exposure to bakhoor, the use of oral steroids, and the number of ICU admission as strong indicators for uncontrolled asthma in children. An adaptive national strategy should be designed to enable effective and personalized interventions, resources, and objectives for maximized benefits.

Effects of acupoint herbal patching as an add-on to asthma medication during Sanfu days, as the hottest days in summer, on the acute attack, the immunological response, and the pulmonary function in asthmatic children: A meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the effect of acupoint herbal patching as an add-on to asthma medication during Sanfu days, as the hottest days in summer, on the acute attack, immunological response, and the pulmonary function in asthmatic children.

METHODS

A systematic literature search up to July 2021 was performed and 13 studies included 1166 asthmatic children at the start of the study; 587 of them were using acupoint herbal patching as an add-on to asthma medication during Sanfu days and 579 were given asthma medication only.

RESULTS

Acupoint herbal patching as add-on to asthma medication had significantly lower frequency of acute attack (mean difference [MD], -1.57; 95% confidence interval [CI], -2.28 to -0.85, P < .001), lower asthma relapse (odds ratio, 0.13; 95% CI, 0.04-0.43, P < .001), and higher forced expiratory volume in 1 second (MD, 1.72; 95% CI, 0.89-2.65, P < .001), higher peak expiratory flow rate (MD, 1.15; 95% CI, 0.37-1.93, P = .004), lower immunoglobulin E after treatment (MD, -123.81; 95% CI, -185.60 to -62.02, P < .001), and higher interferon-gamma after treatment (MD, 7.17; 95% CI, 2.42-11.92, P = .003) compared to asthma medication only in asthmatic children.

CONCLUSIONS

Acupoint herbal patching as an add-on to asthma medication during Sanfu days had a significantly lower frequency of acute attack, lower asthma relapse, higher forced expiratory volume in 1 second, higher peak expiratory flow rate, and higher interferon-gamma after treatment in asthmatic children compared to asthma medication only in asthmatic children.

Can the response to a single dose of beclomethasone dipropionate predict the outcome of long-term treatment in childhood exercise-induced bronchoconstriction?

BACKGROUND

Exercise-induced bronchoconstriction (EIB) is a frequent and highly specific symptom of childhood asthma. Inhaled corticosteroids (ICS) are the mainstay of controller therapy for EIB and asthma; however, a proportion of asthmatic children and adolescents is less responsive to ICS. We hypothesized that a single dose response to ICS could function as a predictor for individual long-term efficacy of ICS.

OBJECTIVE

To assess the predictive value of the bronchoprotective effect of a single-dose beclomethasone dipropionate (BDP) against EIB for the bronchoprotective effect of 4 weeks of treatment, using an exercise challenge test (ECT).

METHODS

Thirty-two steroid-naïve children and adolescents aged 6 to 18 years with EIB were included in this prospective cohort study. They performed an ECT at baseline, after a single-dose BDP (200µg) and after 4 weeks of BDP treatment (100 µg twice daily) to assess EIB severity.

RESULTS

The response to a single-dose BDP on exercise-induced fall in FEV1 showed a significant correlation with the response on exercise-induced fall in FEV1 after 4 weeks of BDP treatment (r = .38, p = .004). A reduction in post-exercise fall in FEV1 of more than 8% after a single-dose BDP could predict BDP efficacy against EIB after 4 weeks of treatment with a positive predictive value of 100% (CI: 86.1-100%) and a negative predictive value of 29.4% (CI: 11.7%-53.7%).

CONCLUSION

We found that the individual response to a single-dose BDP against EIB has a predictive value for the efficacy of long-term treatment with BDP. This could support clinicians in providing personalized management of EIB in childhood asthma.

MALT1 in asthma children: A potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation

BACKGROUND

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) participates in the immune-related allergic response and inflammation flare, while its clinical role in asthma children is still unknown. Herein, this study aimed to investigate MALT1 expression, and its correlation with exacerbation risk, T helper (Th)1, Th2 cells (and their secreted cytokines), as well as inflammatory cytokines in asthma children.

METHODS

Sixty children with asthma exacerbation and 60 children with remission asthma were enrolled in this study; then their blood MALT1, Th1, Th2 cells, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interferon-gamma (IFN-γ), and interleukin-4 (IL-4) were detected. Besides, blood MALT1 in another 20 health controls was also determined.

RESULTS

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 was highest in children with asthma exacerbation, followed by children with remission asthma, and lowest in health controls (p < 0.001). MALT1 could distinguish children with asthma exacerbation from children with remission asthma (area under the curve (AUC): 0.757, 95% CI: 0.670-0.843). In children with asthma exacerbation, MALT1 was negatively linked with IFN-γ (p = 0.002) and Th1 cells (p = 0.050), but positively related to Th2 cells (p = 0.027) and exhibited a positive correlation trend (without statistical significance) with IL-4 (p = 0.066); meanwhile, MALT1 was positively correlated with exacerbation severity (p = 0.010) and TNF-α (p = 0.003), but not linked with IL-6 (p = 0.096). In children with remission asthma, MALT1 only was negatively associated with Th1 cells (p = 0.023), but positively linked with TNF-α (p = 0.023).

CONCLUSION

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 serves as a potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation of asthma children.

The influence of childhood asthma on adult height: evidence from the UK Biobank

BACKGROUND

To elucidate the influence of childhood asthma on adult height after consideration of genetic heterogeneity in height.

METHODS

Based on the UK Biobank, we conducted a matched cohort study, including 13,602 European individuals with asthma diagnosed before 18 years old and 136,008 matched unexposed individuals without such an experience. Ascertainment of asthma was based on self-reported data (97.6%) or clinical diagnosis in healthcare registers (2.4%). We studied three height outcomes, including (1) the attained adult height (in centimeters), (2) the height deviation measured as the difference between a person's rank of genetically determined height (based on generated polygenetic risk score) and their rank of attained adult height in the study population (deviation in % of height order after standardization), and (3) the presence of height deficit comparing genetically determined and attained height (yes or no). We applied linear mixed-effect models to assess the associations of asthma diagnosed at different ages with attained adult height and height deviation, and conditional logistic regression models to estimate the associations of asthma with the risk of height deficit.

RESULTS

40.07% (59,944/149,610) of the study participants were born before 1950, and most of them were men (57.65%). After controlling for multiple covariates, childhood asthma was associated with shorter attained adult height, irrespective of age at asthma diagnosis. However, in the analysis of height deviation (deviation in %), we observed the greatest height deviation among individuals with asthma diagnosed before 4 years of age (- 2.57 [95% CI - 4.14 to - 1.00] and - 2.80 [95% CI - 4.06 to - 1.54] for the age of ≤ 2 and 3-4 years, respectively). The magnitude of height deviation in relation to asthma declined thereafter and became null after age 6. Similarly, there was a statistically significant height deficit in relation to an asthma diagnosis at ages ≤ 2 and 3-4 (odds ratios = 1.21, 95% CI 1.04 to 1.40, and 1.15, 95% CI 1.02 to 1.29) but not thereafter. The result pattern was similar when separately analyzing asthma with or without inhaled glucocorticoid (ICS) use, despite that the estimates were consistently stronger among asthma individuals who used ICS.

CONCLUSIONS

Our results suggest a notable association of childhood asthma, primarily asthma diagnosed at an early age, with adult height, after consideration of genetic heterogeneity in height and use of ICS. This finding highlights the need for surveillance on the growth problems among children with asthma.

Keeping Pace with Adolescent Asthma: A Practical Approach to Optimizing Care

Known for their pre-occupation with body image, self-identity creation, peer acceptance, and risk-taking behaviors, adolescents with asthma face unique challenges. Asthma is a heterogeneous disease and accurate diagnosis requires assessment through detailed clinical history, examination, and objective tests. Diagnostic challenges exist as many adolescents can present with asthma-like symptoms but do not respond to asthma treatment and risk being mis-diagnosed. Under-recognition of asthma symptoms and denial of disease severity must also be addressed. The over-reliance on short-acting beta-agonists in the absence of anti-inflammatory therapy for asthma is now deemed unsafe. Adolescents with mild asthma benefit from symptom-driven treatment with combination inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA) on an as-required basis. For those with moderate-to-persistent asthma requiring daily controller therapy, maintenance and reliever therapy using the same ICS-LABA controller simplifies treatment regimes, while serving to reduce exacerbation risk. A developmentally staged approach based on factors affecting asthma control in early, middle, and late adolescence enables better understanding of the individual's therapeutic needs. Biological, psychological, and social factors help formulate a risk assessment profile in adolescents with difficult-to-treat and severe asthma. Smoking increases risks of developing asthma symptoms, lung function deterioration, and asthma exacerbations. Morbidity associated with e-cigarettes or vaping calls for robust efforts towards smoking and vaping cessation and abstinence. As adolescents progress from child-centered to adult-oriented care, coordination and planning are required to improve their self-efficacy to ready them for transition. Frequent flare-ups of asthma can delay academic attainment and adversely affect social and physical development. In tandem with healthcare providers, community and schools can link up to help shoulder this burden, optimizing care for adolescents with asthma.

Neuropsychiatric side reactions of leukotriene receptor antagonist, antihistamine, and inhaled corticosteroid: A real-world analysis of the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS)

BACKGROUND

There are limited real-world studies on the differences in leukotriene receptor antagonists (LTRA), H1-antihistamines (H1-AH), and inhaled corticosteroids (ICS) associated neuropsychiatric events. In this study, we aimed to analyze the characteristics of drug associated neuropsychiatric events, and compare the differences among different drug categories.

METHODS

Disproportionality analysis and Bayesian analysis were used in data mining to identify suspected neuropsychiatric events associated with LTRA, H1-AH, and ICS based on the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) from January 2004 to September 2020. Demographic information, time interval to onset, and death rates of LTRA, H1-AH, and ICS-associated neuropsychiatric events were also analyzed.

RESULTS

A total of 9475 neuropsychiatric events were identified. The number of neuropsychiatric events related to LTRA, H1-AH, and ICS were 5201 (54.89%), 3226 (34.05%), and 1048 (11.06%), respectively. LTRA related neuropsychiatric events were more common in patients aged 4-6 years (18.66%). H1-AH and ICS related neuropsychiatric events were more common in patients aged 18-44 years (29.92%) and older than 65 years (30.60%), respectively. Montelukast was highly associated with neuropsychiatric events, with a high reporting odds ratio (ROR). Most neuropsychiatric symptoms occurred within the first 10 days after drug initiation (78.63% for LTRA, 91.39% for H1-AH, and 84.07% for ICS). The death rate due to neuropsychiatric events of first generation H1-AH was significantly higher than that of LTRA and ICS (p < 0.001).

CONCLUSIONS

LTRA associated neuropsychiatric events reported in FAERS were most frequent in 4 to 6-year-old children. Most reported cases occurred within the first 10 days after drug initiation. The second generation H1-AH was relatively safe for neuropsychiatric events compared with the first generation. The fatality rate due to first generation H1-AH associated neuropsychiatric events was higher than that of LTRA and ICS. More attention should be paid to specific patients treated with LTRA and H1-AH.

Normal growth variance by Z scores should be considered when interpreting the growth inhibitory effect of inhaled corticosteroids

BACKGROUND

Randomized clinical trials suggest that long-term inhaled corticosteroid (ICS) treatment significantly inhibits growth velocity (GV) assessed by centimeters/year (cm/year) in primarily prepubescent, mild asthmatics. However, several observational studies measuring normal growth variance by Z score suggest the absence of the ICS inhibitory effect.

OBJECTIVE

To demonstrate the generalizability of ICS growth inhibition in cm/year by establishing whether this measure exceeds the expected normal changes in GV by Z score for similar age and sex.

METHODS

This was a retrospective, observational study comparing height and GV across a 2 year period in asthmatics aged 2-10 years, receiving ICS therapy (Group 3) with non-asthmatics, and non-ICS asthmatics (Groups 1 and 2), respectively. Generalized linear model procedure compared GV measures after adjustment for age, gender, and dependence of group differences on the age of the child.

RESULTS

Before initiation of ICS therapy at baseline, Group 3 patients (n = 22) were shorter than Groups 1 (n = 67) and 2 (n = 44) by mean height in cm, and height for age Z score in the adjusted model (p < .05). GV was also significantly reduced in Group 3 after initiation of ICS therapy versus Groups 1 and 2 by 1.0-1.5 cm/year, respectively, p < .05, but not significantly in comparison to expected normal GV variance determined by Z score, p ≥ .05.

CONCLUSION

Our findings suggest the need to consider normal growth variance by Z scores in addition to absolute changes (cm/year) when interpreting the inhibitory effect of ICS on GV. Larger sample size studies will be necessary to confirm our findings.

Molecular mechanisms of An-Chuan Granule for the treatment of asthma based on a network pharmacology approach and experimental validation

An-Chuan Granule (ACG), a traditional Chinese medicine (TCM) formula, is an effective treatment for asthma but its pharmacological mechanism remains poorly understood. In the present study, network pharmacology was applied to explore the potential mechanism of ACG in the treatment of asthma. The tumor necrosis factor (TNF), Toll-like receptor (TLR), and Th17 cell differentiation-related, nucleotide-binding oligomerization domain (NOD)-like receptor, and NF-kappaB pathways were identified as the most significant signaling pathways involved in the therapeutic effect of ACG on asthma. A mouse asthma model was established using ovalbumin (OVA) to verify the effect of ACG and the underlying mechanism. The results showed that ACG treatment not only attenuated the clinical symptoms, but also reduced inflammatory cell infiltration, mucus secretion and MUC5AC production in lung tissue of asthmatic mice. In addition, ACG treatment notably decreased the inflammatory cell numbers in bronchoalveolar lavage fluid (BALF) and the levels of pro-inflammatory cytokines (including IL-6, IL-17, IL-23, TNF-alpha, IL-1beta and TGF-beta) in lung tissue of asthmatic mice. In addition, ACG treatment remarkably down-regulated the expression of TLR4, p-P65, NLRP3, Caspase-1 and adenosquamous carcinoma (ASC) in lung tissue. Further, ACG treatment decreased the expression of receptor-related orphan receptor (RORγt) in lung tissue but increased that of Forkhead box (Foxp3). In conclusion, the above results demonstrate that ACG alleviates the severity of asthma in a ´multi-compound and multi-target’ manner, which provides a basis for better understanding of the application of ACG in the treatment of asthma.

Toxic stress, health and nutrition among Brazilian children in shelters

Background

Living in a shelter is an adverse experience that generates toxic stress. This situation can cause the dysregulation of the hypothalamic-pituitary-adrenal axis and exert a negative impact on health.The aim of the present study was to determine the association between toxic stress and social, clinical and nutritional characteristics in children at welfare institutions in a city of northeastern of Brazil.

Methods

An analytical, cross-sectional study was conducted with male and female children up to 60 months of age who live in shelters. Hair cortisol was used for the assessment of stress (immunoassay). The anthropometric data collected were height for age, body mass index for age, arm circumference for age, and head circumference for age (expressed in z-scores). We also evaluated food intake using markers proposed by the Brazilian Dietary and Nutritional Vigilance Surveillance System as well as the occurrence of dental caries and anemia.

Results

Sixty-three children one to 60 months of age participated in the present study. Asthma was the most frequent disease (11.1%). The prevalence of short stature, anemia and dental caries in the sample was 22.2, 22.2 and 9.4%, respectively. Cortisol levels ranged from 0.93 pg/mg to 391.29 pg/mg (median: 6.17 pg/mg). Higher cortisol levels were found in children with illnesses (p = 0.012) and those who had been hospitalized after being admitted to the institutions (p = 0.001).

Conclusions

The majority of children had unhealthy eating behavior. The cortisol concentrations found in the present study were suggestive of dysregulation of the hypothalamic-pituitary-adrenal axis. Hypercortisolism was associated with illness and hospitalization.

Montelukast use over the past 20 years: monitoring of its effects and safety issues

Montelukast, a leukotriene receptor antagonist, was launched 20 years ago in Korea. It is recommended as an alternative treatment for asthma in children with mild persistent symptoms or as an add-on treatment to existing low-dose inhaled corticosteroids (ICSs) in children who require additional treatment. However, in the real-world setting, many doctors and patients prefer montelukast over ICSs despite their lower efficacy. Although montelukast is considered to be a safe drug, there are concerns regarding adverse drug reactions, including the rare occurrence of Churg-Strauss syndrome and, despite insufficient data, the possibility of neuropsychiatric events such as anxiety, depression, sleep disturbance, and suicidality. This review identified that montelukast has significantly contributed to asthma control over the past 20 years in Korea and has been critical for reducing asthma severity, especially early wheezing and disease control. Our findings suggest that the effects of montelukast treatment can be monitored by measuring serum eosinophilderived neurotoxin levels.

Preschool Wheezing: Trajectories and Long-Term Treatment

Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.

2020 Brazilian Thoracic Association recommendations for the management of asthma

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

The global initiative for asthma guidelines (2019): change in the recommendation for the management of mild asthma based on the SYGMA-2 trial - A critical appraisal

The Global Initiative for Asthma (GINA) recently released their updated Global Strategy for Asthma Management and Prevention Guide (2019). The pocket guide for practicing clinicians states that "the 2019 GINA strategy report represents the most important change in asthma management in 30 years." An important recommendation is the change in treatment strategy for the management of mild asthma where the guideline recommends that" all adults and adolescents with asthma should receive either symptom driven (in mild asthma) or daily low dose inhaled corticosteroid (ICS) containing controller treatment to reduce the risk of serious exacerbations." Our study critically appraises the SYGMA-2 trial, a key trial that largely formed the basis of this recommendation and discusses the potential consequences of using only long-acting beta-2-agonist + ICS as needed as against regular, daily low-dose ICS with as-needed short-acting beta-2-agonist. Our critique covers airway inflammation, disease heterogeneity, understanding the noninferiority margin and its consequences, the Hawthorne effect, and conflict of interest. It is our view that statement of this magnitude will have far-reaching implications for clinical practice which will be in the interests of some patients but also against the interests of others.

Acupoint herbal patching during Sanfu Days on reducing frequency of acute asthma attack in children: A systematic review and meta-analysis

OBJECTIVE

Acupoint herbal patching (AHP) is an external therapy of Traditional Chinese Medicine. This systematic review and meta-analysis sought to evaluate whether AHP during Sanfu Days has additional benefits in children with asthma.

METHODS

A comprehensively electronic literature search was performed in the Cochrane Library, PubMed, Embase, CNKI, VIP, and WanFang databases from their inception to March 2019. Randomized controlled trials that evaluated the AHP during Sanfu Days treatment for pediatric asthma were included. The main outcome measures were frequency of acute asthma attack, relapse of asthma, and pulmonary function.

RESULTS

Eleven trials involving 882 children with asthma were identified. White mustard seed, rhizoma corydalis, and radix kansui were the most frequently used herbs. Adjunctive treatment with AHP significantly reduced the frequency of acute asthma attack (mean difference [MD] -1.62 times/year; 95% confidence intervals [CI] -2.13 to -1.11). Moreover, AHP improved the peak expiratory flow (standardized mean differences [SMD] 0.61; 95% CI 0.39-0.82) and forced expiratory volume in 1 s (SMD 0.48; 95% CI 0.31-0.66).

CONCLUSIONS

Application of AHP during Sanfu Days has additional benefits in reducing the frequency of acute attack and improving pulmonary function in children with asthma. However, the current findings should be interpreted with caution owing to the methodological flaws of the analyzed trials.

Inhaled corticosteroids in children with persistent asthma: effects of different drugs and delivery devices on growth

BACKGROUND

Inhaled corticosteroids (ICS) are the most effective treatment for children with persistent asthma. Although treatment with ICS is generally considered to be safe in children, the potential adverse effects of these drugs on growth remains a matter of concern for parents and physicians.

OBJECTIVES

To assess the impact of different inhaled corticosteroid drugs and delivery devices on the linear growth of children with persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, which is derived from systematic searches of bibliographic databases including CENTRAL, MEDLINE, Embase, CINAHL, AMED and PsycINFO. We handsearched respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov and manufacturers' clinical trial databases, or contacted the manufacturer, to search for potential relevant unpublished studies. The literature search was initially conducted in September 2014, and updated in November 2015, September 2018, and April 2019.

SELECTION CRITERIA

We selected parallel-group randomized controlled trials of at least three months' duration. To be included, trials had to compare linear growth between different inhaled corticosteroid molecules at equivalent doses, delivered by the same type of device, or between different devices used to deliver the same inhaled corticosteroid molecule at the same dose, in children up to 18 years of age with persistent asthma.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies and assessed risk of bias in included studies. The data were extracted by one author and checked by another. The primary outcome was linear growth velocity. We conducted meta-analyses using Review Manager 5.3 software. We used mean differences (MDs) and 95% confidence intervals (CIs ) as the metrics for treatment effects, and the random-effects model for meta-analyses. We did not perform planned subgroup analyses due to there being too few included trials.

MAIN RESULTS

We included six randomized trials involving 1199 children aged from 4 to 12 years (per-protocol population: 1008), with mild-to-moderate persistent asthma. Two trials were from single hospitals, and the remaining four trials were multicentre studies. The duration of trials varied from six to 20 months.One trial with 23 participants compared fluticasone with beclomethasone, and showed that fluticasone given at an equivalent dose was associated with a significant greater linear growth velocity (MD 0.81 cm/year, 95% CI 0.46 to 1.16, low certainty evidence). Three trials compared fluticasone with budesonide. Fluticasone given at an equivalent dose had a less suppressive effect than budesonide on growth, as measured by change in height over a period from 20 weeks to 12 months (MD 0.97 cm, 95% CI 0.62 to 1.32; 2 trials, 359 participants; moderate certainty evidence). However, we observed no significant difference in linear growth velocity between fluticasone and budesonide at equivalent doses (MD 0.39 cm/year, 95% CI -0.94 to 1.73; 2 trials, 236 participants; very low certainty evidence).Two trials compared inhalation devices. One trial with 212 participants revealed a comparable linear growth velocity between beclomethasone administered via hydrofluoroalkane-metered dose inhaler (HFA-MDI) and beclomethasone administered via chlorofluorocarbon-metered dose inhaler (CFC-MDI) at an equivalent dose (MD -0.44 cm/year, 95% CI -1.00 to 0.12; low certainty evidence). Another trial with 229 participants showed a small but statistically significant greater increase in height over a period of six months in favour of budesonide via Easyhaler, compared to budesonide given at the same dose via Turbuhaler (MD 0.37 cm, 95% CI 0.12 to 0.62; low certainty evidence).

AUTHORS' CONCLUSIONS

This review suggests that the drug molecule and delivery device may impact the effect size of ICS on growth in children with persistent asthma. Fluticasone at an equivalent dose seems to inhibit growth less than beclomethasone and budesonide. Easyhaler is likely to have less adverse effect on growth than Turbuhaler when used for delivery of budesonide. However, the evidence from this systematic review of head-to-head trials is not certain enough to inform the selection of inhaled corticosteroid or inhalation device for the treatment of children with persistent asthma. Further studies are needed, and pragmatic trials and real-life observational studies seem more attractive and feasible.